Thoracic aneurysmectomy utilizing direct left ventriculofemoral shunt (TDMAC-heparin) bypass.

Use of a temporary heparin-coated ventriculofemoral shunt in 2 patients in the successful management of traumatic aneurysms of the descending thoracic aorta is described. Safe and effective bypass protection can be achieved by direct ventriculofemoral diversion when cannulation of the left subclavian artery or ascending aorta is hazardous. The use of a heparinized shunt bypass without systemic anticoagulation considerably simplifies the operation.     

Early sternal erosion and luetic aneurysms of thoracic aorta: report of 6 cases and analysis of cause-effect relationship.

Six patients with luetic aneurysm of the ascending aorta eroding the sternum are presented. The erosion was an early and principal presentation and the site of erosion and location and morphology of aneurysm were identical in all six patients. The erosion mainly affected the right half of the manubrium and medial end of right clavicle. The aneurysms arose from the junction of the ascending and transverse arches of the thoracic aorta and had narrow opening close to the origin of the innominate artery. The identical presentation, aetiology, angiographic location and morphology, corroborated further at surgery, suggests that syphilitic aneurysms in this location have a strong tendency to cause early sternal erosion.     

Surgery of the descending thoracic aorta: spinal cord protection with the Gott shunt

From July, 1974, to July, 1987, surgical treatment of descending thoracic aortic aneurysms was performed in 173 patients at l'H?pital du Sacré-Coeur de Montréal. The cause of the aneurysms was arteriosclerosis or medial degeneration in 83 patients, trauma in 50, dissection in 34, and a congenital malformation in 6. A single method of external shunting provided distal perfusion in all patients in the series. A 9-mm Gott aneurysm shunt was placed preferentially between the ascending aorta (67%) and the descending aorta (60%). Alternative sites of proximal cannulation (aortic arch, 9%; proximal descending aorta, 22%; left ventricle, 2%) and distal cannulation (abdominal aorta, 3%; left femoral artery, 37%) were chosen based on the location and the extent of the aortic aneurysm. No systemic heparinization was used. In the last 40 patients, a flowmeter adapted for use with the shunt allowed the recording of shunt flow (mean, 2,475 ml/min; range, 1,100 to 4,000 ml/min). Hospital mortality, including patients with ruptured aneurysms, was 15% (26/173). The mean aortic cross-clamp time was 37 minutes (range, 8 to 105 minutes). Of the 173 patients, 168 survived long enough to allow accurate clinical evaluation of the function of the spinal cord: no paraplegia or other spinal cord ischemic injury occurred. To date, our clinical experience has demonstrated the effectiveness of the 9-mm Gott shunt in preserving the functional integrity of the spinal cord during cross-clamping of the thoracic aorta.     

Surgical repair of dissection of the upper descending thoracic aorta and discrete ascending aortic aneurysm.

This report describes successful staged surgical repair in 2 patients with dissection of the upper descending thoracic aorta (DeBakey type III) with coexisting discrete Marfan's aneurysms of the ascending aorta. Initial repair of the descending aortic dissection was done through a left thoracotomy using a transverse aorta--femoral artery shunt in 1 patient and a left ventricular apex--femoral artery shunt without systemic heparinization in the other. Emphasis is placed on the need for pharmacological reduction of blood pressure during aortic cross-clamping as well as the use of a shunt to prevent dissection of the ascending aortic aneurysm. In both patients, subsequent repair of the ascending aortic aneurysm was accomplished using composite graft replacement of the aortic valve and ascending aorta. This operation is advised for such patients even in the absence of notable aortic valve incompetence.     

Measurement of spinal cord ischemia during operations upon the thoracic aorta: initial clinical experience.

Paraplegia has been an unpredictable, devasting complication following operations upon the thoracoabdominal aorta for over 30 years. The frequency ranges from 0.5% with operations for coarctation to as high as 15% following surgery for thoracoabdominal aneurysms. Both uncertainty and controversy exist about the value of different protective methods during aortic crossclamping (AXC): heparinized shunts, partial bypass, and reimplantation of intercostal arteries. This report describes the authors' initial clinical experience with a highly sensitive indicator of spinal cord ischemia, somatosensory evoked potentials (SEP) in an attempt to prevent paraplegia associated with surgical procedures on the thoracoabdominal aorta. Seven consecutive patients (one coarctation, five thoracic aneurysms, one thoracoabdominal aneurysm) underwent continuous operative monitoring of SEP. Cortical response to simultaneous electrical stimulation (20 mAmps, 0.6 mSec., 2.3 cps) of both the right and left posterior tibial nerves was recorded before, during, and after AXC, and following operation. When ischemic changes were detected by SEP, increasing distal circulation by different maneuvers (heparinized shunt, femoral-femoral bypass, reimplantation of intercostal arteries) reversed these changes. In two patients with thoracic aneurysms, ischemic changes appeared within three minutes after AXC and all potentials disappeared in nine minutes. Rapid insertion of a graft (AXC 28 and 37 minutes) resulted in SEP return 40 minutes following restoration of flow. These changes were prevented by a heparinized shunt in two patients, femoral/femoral bypass in one, and T8-T9 intercostal reimplantation in one. No SEP changes occurred in the patient with coarctation. No postoperative neurologic complications occurred. Continuous operative monitoring of SEP has exciting possibilities for preventing paraplegia. It is simple, highly sensitive, and seems to provide a precise measurement of adequacy of circulation to the spinal cord.     

Use of the BioMedicus centrifugal pump in traumatic tears of the thoracic aorta

Traumatic blunt thoracic aortic injury is a clinical entity of increasing incidence. After the diagnosis of traumatic tear of the aorta is made, there is some controversy over whether the aorta should be repaired using cardiopulmonary bypass, a heparinized shunt, or cross-clamping and graft interposition without a shunt or bypass. At Allegheny General Hospital, 19 patients were treated for traumatic tears of the thoracic aorta between July 1, 1977, and June 30, 1983. They can be divided into two groups: Group 1 (July 1, 1977, through October 31, 1981), in which no shunt or bypass or only a heparinized shunt was used, and Group 2 (November 1, 1981, through June 30, 1983), in which left atrium-femoral artery bypass was performed using a BioMedicus heparinless pump and tubing. Among the 10 patients in Group 1, 4 died and 2 had paraplegia postoperatively. Among the 9 patients in Group 2, 1 died and none experienced paraplegia following operation. We believe that the BioMedicus centrifugal pump is a simple, safe means of perfusing the lower body, kidneys, and spinal column without necessitating heparinization in a patient with multiple injuries or the placement of a cumbersome heparinized shunt. Because of the simplicity and the reliability demonstrated, this pump should be considered for use in all patients with traumatic tears of the thoracic aorta.     

Debatable questions in the surgical treatment of thoracic aortic aneurysms

Some controversies in the surgical approach to thoracic aortic aneurysms are discussed. The author recommends: to perform echocardiography in patients with aortic aneurysms for detection of intracardiac pathology which may complicate the postoperative course; to combine thoracic aortography with selective coronary angiography in patients with thoracic aortic aneurysm for diagnosis of coronary artery disease; to operate asymptomatic fusiform aneurysm that measure twice or more the size of the normal aorta; to resect and replace dissections of the ascending aorta during cardio-pulmonary bypass; and to use active shunts during resection of the descending and thoraco-abdominal aneurysm.     

支架型人工血管腔内治疗复杂主动脉瘤

目的：总结15例应用支架治疗复杂动脉瘤的初步经验。方法：Ⅲ型夹层动脉瘤者主动脉极度扭曲1例；破口在弓部的Ⅲ型夹层动脉瘤1例，需先行左右颈-颈和左右腋．腋动脉人工血管搭桥后再封闭左侧颈总动脉和锁骨下动脉：Ⅲ型夹层动脉瘤近侧破口来自于变异发出的右锁骨下动脉1例；Ⅲ型夹层动脉瘤合并肠系膜上动脉几乎完全闭塞和肠缺血1例；Ⅲ型夹层动脉瘤真假腔难判断者4例；腹主动脉瘤瘤颈长度〈1cm需开窗型支架治疗1例；破裂腹主动脉瘤1例：5枚支架治疗胸腹主动脉瘤1例；腹主动脉瘤瘤颈夹角为90。2例；主动脉溃疡紧邻腹腔动脉，需开窗型支架开窗型人工血管治疗1；肝动脉瘤腹腔动脉瘤合并动静脉瘘1例。结果：15例病人经支架治疗均获得成功。结论：支架型人工血管治疗复杂动脉瘤为微创方法，但需严密设计。     

Thoracoabdominal aortic aneurysm associated with umbilical artery catheterization: case report and review of the literature.

Aneurysms in infants and children are rare and are usually associated with cardiovascular malformations or connective tissue disorders. A new subgroup of patients has become recognized over the past two decades--those with aneurysms associated with umbilical artery catheterization. Critically ill newborns who have required umbilical artery catheterization and have developed sepsis, usually staphylococcal, are at risk for the development of mycotic aneurysm disease of the aorta or its major branches or both. Since first described in 1970, 34 cases have been reported in the literature, 14 involving the descending thoracic aorta, 10 the abdominal aorta, 6 the iliac arteries, and 4 either the thoracoabdominal aorta or multiple aneurysms involving both the thoracic and abdominal aorta. This report presents a case we recently treated of a 15-month-old-boy with a large thoracoabdominal aortic aneurysm and aneurysms of the infrarenal abdominal aorta and proximal right common iliac artery. It includes a review of the recent literature to analyze pathogenesis, clinical manifestations, and to formulate methods of treatment.     

Use of the Gott shunt in the prosthetic replacement of the aortic arch]

Our previous experience in 272 consecutive cases of descending thoracic aortic aneurysms resected without paraplegia by using the 9 mm Gott shunt encouraged us to apply the same technique to more complex aortic surgery. Graft replacement of the transverse aortic arch with brachio-cephalic vessel reattachment was undertaken in 2 patients without the aid of extracorporeal circulation and without systemic heparinisation. Body perfusion was achieved with two 9 mm Gott shunts inserted between the ascending aorta and both femoral arteries. A 10 mm graft interposition between the shunts and the femoral arteries allowed for retrograde perfusion and distal leg irrigation. Blood supply to the brain was maintained with the cut halves of a 7 mm Gott shunt connected as side branches to one of the 9 mm shunts, allowing cannulation of the innominate ant the left carotid arteries. In 90 of the 272 patients treated for a descending aortic aneurysm, a mean shunt flow of 2526 ml/min. was recorded through the 9 mm Gott shunt and from there, we took for granted that the total cardiac output, in there 2 patients, could be propelled by using 2 shunts. During aortic cross clamping, there were no change in the filling pressure of either the right heart or the left heart, and no metabolic acidosis was observed. Both patients survived with normal physiological function of all organs including the brain and the spinal cord.     

Circulatory support during crossclamping of the descending thoracic aorta. Evidence of improved organ perfusion

The need to support the distal circulation during aortic crossclamping and the subsequent effects on hemodynamics and organ perfusion prompted our review of 51 patients who underwent repair of aneurysm of the descending thoracic aorta from 1983 through 1987. Forty-three patients had aneurysms originating distal to the left subclavian artery, and eight had aneurysms involving the distal aortic arch and the proximal descending aorta; 10 patients had emergency operation for aneurysm rupture. Three different techniques were used: Seventeen patients had left atrial-distal aorta arterial bypass with a centrifugal pump, 18 patients had a Gott shunt, and 16 patients had no circulatory support during aneurysm repair. Location and type of aneurysm, age, sex, diabetes, preoperative hypertension, and serum lipid levels were similar in the three groups. Duration of crossclamping was 54 +/- 12 minutes for left atrial-aortic assist, 45 +/- 5 for the shunt group, and 34 +/- 4 for patients without circulatory support. With crossclamping, all groups had similar and significant increases in heart rate (p less than 0.03). Proximal systolic blood pressure did not change during left atrial-aortic assist, but a transient increase occurred in patients with shunts (p less than 0.01), and a sustained increase occurred in patients without circulatory support (p less than 0.05). With crossclamp release, arterial pH and capillary pulmonary wedge pressure decreased significantly (p less than 0.05) in patients without shunt or bypass. Postoperative renal function did not vary significantly when circulatory support was used, but serum creatinine rose transiently in patients with unsupported aortic crossclamping. We conclude that support of the distal circulation during thoracic aortic crossclamping stabilizes hemodynamics and prevents systemic acidosis and renal ischemia. Further, our data suggest that the centrifugal pump may provide better protection than a passive shunt.     

经颈动脉腔内技术重建主动脉弓治疗Stanford A型夹层动脉瘤(附1例报告)

目的探讨血管腔内技术重建主动脉弓治疗升主动脉、主动脉弓病变的可行性。方法2005年,对1例StanfordA型夹层动脉瘤,腔内修复主动脉病变之前做右颈总动脉-左颈总动脉-左锁骨下动脉的旁路术;经右颈总动脉将修改的分叉支架型血管主体放入升主动脉,长臂位于无名动脉。短臂应用延长支架型血管延伸至降主动脉。通过腔内技术重建主动脉弓实现累及升主动脉和主动脉弓主动脉病变的微创治疗。结果腔内修复术后移植物形态良好,血流通畅,病变被隔绝,脑、躯干、四肢循环稳定。无严重并发症。结论该手术方案设计合理、技术可行。可能成为复杂胸主动脉病变新的腔内治疗模式。     

Surgical repair of aneurysms involving the distal aortic arch

The surgical approach to aneurysms involving the transverse aortic arch usually requires either techniques for perfusion or hypothermic circulatory arrest. A simplified approach may be warranted when the aneurysmal process begins in the distal aortic arch and spares the innominate artery. Between November, 1975, and January, 1984, 32 patients (22 men, 10 women; median age 61 years) underwent repair of aneurysms of the distal aortic arch by simple cross-clamping of the diseased aortic segment. In each, the aneurysm arose distal to the innominate artery and involved the arch at the origin of the left subclavian or left common carotid artery. Proximal control was achieved by cross-clamping the aortic arch between the innominate and left carotid arteries. No shunts or extracorporeal bypass circuits were employed. Proximal hypertension was controlled by sodium nitroprusside infusion. All patients were heparinized. A mean aortic cross-clamp time of 27 +/- 10 minutes was required for Dacron graft replacement in 28 patients and Dacron patch repair in three patients. Surgical repair was accomplished successfully in 32 patients. The 30 day mortality was 3% with an in-hospital mortality of 6%. There were no complications as a result of myocardial infarction or stroke. Paraplegia (three patients) was related to cross-clamp time (less than 30 minutes, 0/18; greater than 30 minutes, 3/13 [p less than 0.001]) and distal extent of the aneurysm (localized, 0/22; extensive, 3/9 [p less than 0.001]). Transient renal failure (two patients) was related to cross-clamp time (less than 30 minutes, 0/18; greater than 30 minutes, 2/13 [p less than 0.001]). This experience supports the use of simple aortic cross-clamping for aneurysms of the distal aortic arch, especially if an expeditious repair can be accomplished.     

Totally laparoscopic aortohepatic bypass for aortic debranching during endovascular thoracoabdominal aneurysm repair.

INTRODUCTION: Endovascular grafting of the aorta is gaining widespread acceptance for treating aortic aneurysms. Para-renal aneurysms or thoraco-abdominal aneurysms may be a relative contra-indication for endovascular aneurysm repair (EVAR) unless visceral vessels can be debranched. REPORT: We describe a case of thoraco-abdominal aneurysm extending from the descending thoracic aorta to the level of coeliac artery. A totally laparoscopic retrograde aorto-hepatic bypass was performed in conjunction with endograft exclusion of the aneurysm and coverage of the coeliac artery ostium. DISCUSSION: Laparoscopic debranching of visceral vessels extends the indications of EVAR.     

Surgical treatment of traumatic aneurysm of descending aorta with abnormal right subclavian artery

Among 11 patients with traumatic aneurysms of the descending thoracic aorta, 2 had developmental anomalies of the branches of the arch of the aorta, in particular, independent origin of the right subclavian artery from the descending thoracic aorta. The anomalous right subclavian artery plays the role of a retaining ligament in trauma, and the forming posttraumatic false aneurysm is localized distal of the ostium of the right subclavian artery. The need for clamping the thoracic aorta and both subclavian arteries for the period of aneurysm reconstruction requires catheterization of the arch of the aorta for arterial pressure control. Surgical correction of aneurysm in anomalous origin of the right subclavian artery has peculiarities of its own in the formation of the proximal anastomosis.     

Norwood procedure without circulatory arrest.

In the Norwood procedure for hypoplastic left heart yndrome, the distal descending thoracic aorta was cannulated just superior to the diaphragm through median sternotomy. In combination with cerebral perfusion through the graft anastomosed to the innominate artery, which was used as a systemic-to-pulmonary shunt later, this technique enabled us to completely avoid circulatory arrest and deep hypothermia throughout the operation.     

Cannulation of the innominate artery during surgery of the thoracic aorta: our experience in 55 patients.

BACKGROUND: Alternative cannulation sites such as the right/left axillary artery, the ascending aorta and aortic arch have been recently preferred to the femoral artery to improve neurologic outcome in patients undergoing surgery of the thoracic aorta. In 2004, we started to select the innominate artery as an arterial cannulation site for CPB and antegrade cerebral perfusion institution. Here we present our preliminary experience with 55 patients. METHODS: Between November 2004 and 2006, 55 patients (mean age 60+/-14 years) underwent surgery on the thoracic aorta using the innominate artery as a site for arterial cannulation. Indication for surgery was a degenerative aneurysm in 49 (89.1%), an acute type A dissection in 2 patients (3.6%), a post-dissection aneurysm in 3 (5.4%), a supravalvular aortic stenosis in 1 patient (1.8%). Operative procedure included total arch replacement (n=9), hemiarch replacement (n=6), ascending aorta replacement (n=21), Bentall procedure (n=18) and aortoplasty with patch (n=1). Mean CPB and cross clamp times were 131+/-60 and 95+/-29 min, respectively. Mean cerebral perfusion time was 54+/-26 min. RESULTS: The hospital mortality rate was 3.6%. There were no permanent neurologic dysfunction and one (1.8%) temporary neurological dysfunction. CONCLUSION: Our results with the cannulation of the innominate artery were encouraging. This provides the same advantages of the axillary artery cannulation with greater simplicity and avoiding extra surgical incisions which may be site for local complications. It may represent a valid option for CPB and antegrade cerebral perfusion institution in aortic procedures.     

Subclavian artery aneurysm: an unusual manifestation of Takayasu's arteritis.

Complications of Takayasu's arteritis are typically ischemic in nature because of progressive arterial narrowing, with aneurysm formation occurring as a late sequela. A 30-year-old Black woman with Takayasu's arteritis presented with a progressively enlarging and tender pulsatile mass at the base of the right neck. Upper extremity pulses were intact. Chest computed tomography and aortography demonstrated a 6-cm aneurysm of the right subclavian artery, which originated at the takeoff from the innominate artery, which was also ectatic. There was no evidence of occlusive disease. An operation was performed via the median sternotomy with transverse extension into the supraclavicular area. The distal innominate artery, proximal common carotid artery and entire subclavian artery were resected and replaced with a bifurcated stretch ePTFE graft. The aneurysm was without thrombus or atherosclerosis and all vessels were extremely thick-walled. Pathology revealed healed/healing nonspecific arteritis. Aneurysm formation is an unusual complication of Takayasu's arteritis. Previously reported sites of aneurysm formation include the thoracic and abdominal aorta, the innominate, carotid and superior mesenteric arteries, but not the subclavian artery. Of 28 patients enrolled in a recent clinical protocol at the National Institutes of Health with Takayasu's arteritis, none had aneurysm formation. The authors report surgical repair of a large aneurysm of the right subclavian artery in a young Black woman with Takayasu's arteritis.     

Surgical treatment of giant aneurysms of ascending parts and arch of the aorta in condition of deep hypothermia and circulatory arrest with artificial assisted circulation

Sternotomy in giant (10 cm and more in diameter) aneurysms is highly dangerous due to possibility of injury of aneurysmatic wall with fatal bleeding. That is why sternotomy in condition of artificial circulation (AC) and cooling of patients to 29-30 degrees C are preferred. Two cases of successful surgical treatment of critical patients with giant aneurysms of ascending parts and arch of the aorta in condition of femoro-femoral AC, hypothermia (20 degrees C) and circulatory arrest are presented. One of the patients had a giant false posttraumatic aneurysm of an ascending part of the thoracic aorta with fistula between aneurysm and pulmonary artery. Suturing of defects of ascending aorta and pulmonary artery wall, aneurysmorrhaphia of pulmonary artery were performed. The other patient with acute disruption of a giant dissected aortal aneurysm and hemomediastinum underwent prosthesis of ascending part and arch of the aorta.